Chronic pain and substance use disorders frequently co-occur in VA primary care and addictions treatment settings. The treatment for pain is complicated in Veterans with a history of alcohol or drug misuse because of a potential for abuse and diversion of many prescription pain medications. Thus, treatment providers are left without successful and empirically-supported methods for treating the large number of patients with chronic pain who also have past or current substance use disorders. One potential strategy is to use cognitive-behavioral treatment (CBT) interventions to manage pain and decrease substance use abuse/misuse. Psychosocial interventions such as CBT have demonstrated efficacy for reducing pain and improving functioning in persons with a broad spectrum of pain-related problems. However, this form of treatment has not been explicitly tested in patients with co-occurring substance use disorders.
Our primary objectives were to evaluate the effects of a cognitive behavioral therapy (CBT) intervention, for patients with chronic pain and a substance use disorder, compared to an enhanced usual care (EUC) intervention on measures of pain intensity, pain-related disability, and pain-tolerance. A set of secondary aims will examine if group CBT compared to the EUC condition is associated with greater reductions in illicit substance use over the follow-up time period and whether during-treatment reductions in pain mediate the effect of treatment assignment on later substance use.
Participants were recruited from the Ann Arbor VAMC Substance Abuse Clinic (SAC), High Intensity Outpatient Treatment (HIOT) clinic and/or Intense Outpatient Program. Participants were either identified through presentations made at orientation or via their medical record. Potentially eligible participants consented to complete a brief ten minute survey to help determine full study eligibility. Full study inclusion criteria were: 1) self-reported pain level of moderate (4) or greater on the Numeric Rating Scale; and 2) an intake assessment or orientation (meeting) in the Ann Arbor VA's SAC, HIOT or SUD IOP within the three months prior to making contact with research staff. Exclusion criteria were: 1) acute suicidiality; 2) psychiatric condition that precluded participation in outpatient group treatment (e.g., psychiatric hospitalization in the past 30 days, bizarre thoughts or behavior during the interview); 3) inability to speak and understand English; and 4) the inability to give informed, voluntary, written consent (i.e., a score less than 21 on a Mini-Mental State Examination).
We screened a total of 193 unique individuals for a sample size of 132 participants that consented to participate in the full study. Participants were randomly assigned to the CBT or EUC conditions. Each condition consisted of 10 weekly sessions, lasting approximately one hour in length, led by masters level therapists (i.e., social workers) at the Ann Arbor VAMC. Participants continued to receive their standard of care at the VA. The CBT condition's main foci included cognitive skills, acceptance skills, behavioral skills, life skills and concepts, and relaxation exercises. The EUC condition provided psycho-education about topics such as substance abuse, chronic pain, and how to maintain a healthy lifestyle.
Participants were re-assessed at approximately 3-, 6, and 12-months post-baseline. Each assessment (including the baseline) lasted approximately one hour in length and consisted of surveys/questionnaires, a cold-pressor task, and an urine screen. As part of the surveys/questionnaires, we utilized the Numeric Rating Scale for pain (NRS-I) to measure pain intensity and the General Activity subscale of the West Haven-Yale Multidimensional Pain Inventory (WHYMPI) to measure pain-related disability. Pain tolerance was measured through the use of a cold-pressor task in which participants were asked to immerse their hand/arm into a container of ice water for up to 120 seconds. Participants were also asked to provide a urine sample to determine levels of substances such as heroin, cocaine, marijuana, etc. and to validate self-report measures of abstinence. Medical records were used to identify medications prescribed for pain.
Follow-up rates indicate that over 80% (ranging from 81% to 85%) of assessments were completed at each time period. Mixed model regression analyses were used to examine the impact of random assignment to condition on average value of the outcomes over the follow-up interval (controlling for baseline measure of the same variable).
The sample was, on average 51 years of age, 88% male, and 41% nonwhite. Randomization was mostly successful with the only statistically significant difference between conditions on rate of unemployment (97% in EUC vs. 88% in CBT). Analyses of outcomes over the 12-months indicated that, compared to the EUC condition, those assigned to CBT had significantly greater reductions in pain level [-0.65 (0.29);p <.05], greater improvements in activity level [0.25 (0.11);p <.05] and fewer days of alcohol use [-0.65 (0.27);p < .05] over the 12-month follow-up period. No differences were found on measures of behavioral pain tolerance or days of drug use. Also, participation in the CBT group was associated with greater improvements in confidence to manage pain without substance use [25.3 (8.70);p < .005].
This project provides preliminary data on the efficacy of a pain management intervention, designed for Veterans with co-occurring pain and substance use disorders on pain level, functioning and alcohol use. To the best of our knowledge, this is the first ever study to show a beneficial impact of a psychosocial intervention on pain- and substance-related outcomes in individuals with SUDs. The current results are promising and further research can assist in evaluating the components of interventions that will better enhance care for Veterans, and other populations, experiencing pain and substance use disorders. The development of an empirically validated psychosocial intervention for managing pain and substance misuse can greatly enhance the current set of options for treating Veterans during SUDs treatment.
- Ilgen MA, Bohnert AS, Chermack S, Conran C, Jannausch M, Trafton J, Blow FC. A randomized trial of a pain management intervention for adults receiving substance use disorder treatment. Addiction (Abingdon, England). 2016 Aug 1; 111(8):1385-93.
- Ilgen MA. Parental Health and International, Geographic Proximity. Paper presented at: VA National Pain Management Conference; 2011 Mar 1; Jacksonville, FL.